VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Colonial Manor
8679 Pocahontas Trail
Williamsburg, VA 23185
(757) 476-6721

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Feb. 10, 2023 and May 31, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDINGS AND GROUND

Comments:

Type of inspection: Complaint An unannounced complaint inspection conducted on 2-10-23 LI and LA (A2r 09:15 dep/ 1:45 p). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 2-3-23 regarding allegations in the resident care and related services and buildings and grounds and nutrition. Number of residents present at the facility at the beginning of the inspection: 34 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 0 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-280-A
Complaint related:	Yes
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure it had staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental and psychosocial well-being of each resident as determined by the resident assessments and individualized service plans. Evidence: 1. On 2-10-23 during a complaint inspection, the direct care staff scheduled provided noted one direct care staff schedule on multiple days and shifts to provide services. The facility census on 2-10-23 was thirty-three. The facility has residents assessed at the assisted living level of care requiring assistance with bathing, feeding, incontinent care and transferring. The facility has residents who are non-ambulatory, receiving hospice services and oxygen care. The is one staff to administer the medication from two medication carts. 2. The direct care staff schedule provided on 2-10-23 dated 1-29 to 3-11-23 noted multiple days and shifts with one or no working. The direct care staff schedule dated 1-29 to 2-11-23 noted (6a- 2:30 p shift) noted one staff twelve days and 2p to 10:30p shift noted one staff seven days. The schedule dated 2-12 to 2-25-23 (6a-2:30 p shift) noted one staff fourteen days and 2- to 10:30p shift noted one staff 8 days. The schedule dated 2-26 to 3-11-23 (6a-2:30p shift) noted one staff fourteen days and 2p to 10:30p shift noted one staff eight days. The schedule dated 1-19 to 3-11-23 did not have documentation of direct care staff working on the following dates and shift: 2-3, 2-5, 2-17-, 3-3, 3-4, 3-5, 3-6-23 (6a-2:30 p and 2-10:30p). The schedule did not have a direct staff on the following dates and the 2p to 10:30p shift (2-12 and 2-26-23).
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-H
Complaint related:	No
Description:	Based on record reviewed and staff interviewed the facility failed to ensure an annual reassessment and reassessment due to a significant change in the resident?s condition, using the uniform assessment instrument (UAI) was utilized to determine whether a resident?s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: 1. On 2-10-23, resident #2?s private pay UAI in the record was dated 5-20-20 and 5-20-21. The record did not include a current UAI. The resident?s date of admit noted as 10-8-2008.
Plan of Correction:	The Provider did not provide a Plan of Correction
Standard #:	22VAC40-73-450-B
Complaint related:	No
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was completed by the licensee, administrator, or the designee who has successfully completed the department-approved individualized service plan (ISP) training, provided by a licensed health care professional practicing within the scope of his profession. Evidence: 1. On 2-10-23, staff #1 was asked to provide documentation of Uniform assessment instrument (UAI) and ISP training. Staff did not provide documentation of UAI and ISP training. 2. Staff #1 completed ISP for residents? record reviewed, which were not completed correctly.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: 1. On 2-10-23, resident #1's individualized service plan (ISP) noted and end 10-15-22 date/review date of 10-15-22 and 11-6-22. Staff #1 staff updated all resident?s service plan. The plan was not updated, but it did note staff #1?s signature at the top of the first page of the ISP with a 2. Resident #2?s ISP was dated ?plan year May 2021? and ?revised Nov 7/22. The ISP also noted review date 5-20-22 and 11-7-22. Services to be re-evaluated 5-20-22. 3. Interview with staff #1 revealed staff did not have documentation of UAI and ISP training. Staff stated going through the training a while back.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-870-E
Complaint related:	No
Description:	Based on observation and staff interviewed, the facility failed to ensure all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition. Evidence: 1. On 2-10-23 during a tour of the facility, the dryer in the laundry room near the nursing station was not working. There was another dryer that did not heat, according to staff. The dryer also made a lot of noise when turned on as evidence by the noise heard when the inspector was on the tour with staff #4.
Plan of Correction:	Not available online. Contact Inspector for more information.